Trastornos de Ansiedad Flashcards
8.1.
A 14-year-old boy is brought to the outpatient psychiatrist by
his parents because of a fear of dogs and thunderstorms. When
he encounters one of them he starts breathing heavily,
sweating, complaining of chest pain, and feeling dizzy. As they
live in an area frequented by storms, he has “a panic attack”
three or four times a week. The first time the symptoms
occurred 3 months ago, his parents took him to the emergency
department out of fear that he was having a heart attack. The
workup was negative, and he was given an antianxiety agent to
take on as as-needed basis, which they have been refilling
through his primary care physician. Since then, he has always
carried the medication with him and insists on returning home
if he realizes he does not have it. The school nurse has a supply
of the medication in case he needs it. He avoids sleepovers out
of fear of being embarrassed in front of his peers if he
encounters one of the stressors. What is the most likely
diagnosis?
A. Specific phobia
B. Panic disorder
C. Agoraphobia
D. Generalized anxiety disorder
E. Social phobia
8.1. A. Specific phobia
Though the child shows the same symptoms as those of a panic
attack, and may indeed be having full-blown panic attacks, he cannot
be diagnosed with panic disorder, as the attacks are not unexpected.
Because there are circumscribed triggers, specific phobia is the most
likely diagnosis. He continues to leave the house and go to school,
thus removing agoraphobia as a diagnosis. The fears are
circumscribed and limited to the two stressors, which eliminates
generalized anxiety disorder. Though he avoids some social
situations due to being embarrassed if he were to have a panic attack
in front of his peers, he would not be diagnosed with social anxiety,
as the root cause of the fear is the specific triggers, as opposed to the
social situation itself.
8.2.
The disruption of sleep is a core feature in what anxiety
disorder?
A. Specific phobia
B. Panic disorder
C. Agoraphobia
D. Generalized anxiety disorder
E. Social phobia
8.2. D. Generalized anxiety disorder
Though someone experiencing a panic attack during the night would
most likely experience a disruption in sleep, as would someone who
encountered the trigger of a specific phobia at night, only for
generalized anxiety disorder is sleep disruption a criterion in and of
itself. Likewise, someone with a fear of being embarrassed in a social
situation that was severe enough to warrant a diagnosis of social
anxiety disorder may lose sleep the night before such a situation
would occur, such as giving a speech in class the next day.
8.3.
Panic attacks, on average, last what length of time?
A. 1 to 5 minutes
B. 10 to 15 minutes
C. 20 to 30 minutes
D. 45 to 60 minutes
E. 60 to 90 minutes
8.3. C. 20 to 30 minutes
Panic attacks typically begin with physiologic symptoms of sweating,
tachycardia, shaking, and shortness of breath, as well as
psychological symptoms of impending doom and a feeling that
something is wrong. These symptoms usually peak in about 10
minutes before resolving over the period of the next 10 to 20
minutes, for an average total length of 20 to 30 minutes
8.4.
A 38-year-old investment banker has recently earned a
promotion that now involves giving oral weekly updates to the
senior staff of the company. She has always been afraid of
speaking in public, and would experience insomnia and
gastrointestinal (GI) upset the night before she had to give a
speech in school. She has been told that her first presentation
will occur in 1 week, and calls her primary care physician for
“anything that can help me get through this.” What is the most
appropriate pharmacologic management?
A. Begin a selective serotonin reuptake inhibitors (SSRI)
B. Begin a prn beta-blocker
C. Begin a prn benzodiazepine
D. Begin a prn benzodiazepine and concurrent SSRI
E. Begin a prn beta-blocker and concurrent SSRI
8.4. D. Begin a prn benzodiazepine and concurrent SSRI
Though beta-blockers (specifically propranolol) are often used for
social anxiety disorder, the evidence for its use is scant, and SSRIs
are still considered first-line treatment. Normally, the patient would
be started on an SSRI alone and told that it will take the standard
few weeks for it to become effective. In this case, the patient’s job is
dependent on her performance in the next few days, so she cannot
wait several weeks. Therefore, it would be acceptable to start on a
benzodiazepine for immediate relief, with the understanding that it
will only be used while the SSRI takes effect, after which it will be
discontinued.
8.5.
A 40-year-old woman presents with her wife to the psychiatric
outpatient clinic with a chief complaint of, “I need to be okay
with driving again. This is hampering my job, my social life, my
home life, and is no way to live.” She states that, 3 months ago,
she was driving alone down a busy road when she was
sideswiped by another vehicle. Neither driver was injured
during the accident. However, her vehicle was damaged to the
point that it could not be immediately driven, so she was given
a loaner car at the shop while hers was being repaired. When
she pulled out of the car repair shop parking lot, she was
overcome by an intense wave of fear and pulled over and called
her wife to take her home. Since then, she has experienced the
same fear when attempting to drive, and either depends on her
wife or a ride-sharing service for transportation. She does not
want to use medication “because I don’t want to depend on a
pill.” What should be the first step in psychotherapy for this
patient’s condition?
A. Teaching relaxation techniques
B. Visualization of getting into a car
C. Discussing the reasons she would like to drive
D. Having her drive within the office parking lot
E. Accompanying her on a short drive.
8.5. A. Teaching relaxation techniques
The patient is suffering from a specific phobia, that of driving. The
treatment of choice is graded exposure, in which the patient would
be reintroduced to the elements of driving. For example, she could
begin with visualizing herself behind the wheel of a car or holding
the car keys in her hand and eventually progress to driving in a selfcontained
area, such as the office parking lot, with the end goal of
fully driving by herself. One of the cornerstones of graded exposure
is first learning how to deal with the anxiety that the exposures will
inevitably cause. For that reason, learning relaxation techniques
would be the first step in graded exposure therapy. This patient has
already stated her reasons for wanting to drive, so going through
those again is not likely to yield much, if any, benefit
8.6.
A 39-year-old man presents to the psychiatric outpatient clinic
after experiencing his fifth episode of heart racing, sweating,
dizziness, and shortness of breath in the last 3 weeks. He works
as a chef and states that the first time the symptoms occurred a
month ago, he was working a double shift at his restaurant. He
said nothing about it and waited until the symptoms resolved
on their own, which took about 20 minutes. He felt that he may
have become overstressed and did not think much of it until it
happened again 3 days later. He has had three more episodes
in the past month. He went to the emergency department (ED)
after the third and fourth episodes out of concern about having
a heart attack, and was told, after an extensive cardiac workup,
that his heart was fine. He is worried that he will lose his job if
the episodes continue. He has never been on medications and
has no chronic medical illnesses. Vital signs are temperature
98.0F, BP 150/90, pulse 95, and respirations 18. The
evaluation should include a workup for what medical
condition?
A. Diabetes
B. Lupus
C. Syphilis
D. Hyperthyroidism
E. Pancreatic cancer
8.6. D. Hyperthyroidism
Many medical disorders, such as hypo- or hyperthyroidism,
hyperparathyroidism, and pheochromocytomas, can have symptoms
that resemble panic attacks. This patient increased heart rate and
hypertension, which are signs of hyperthyroidism. Episodic
hypoglycemia associated with insulinomas, but not diabetes in
general can cause symptoms that mimic panic attacks. Pancreatic
cancer can lead to a feeling of doom and anxiety, but not usually
panic attacks. Syphilis and lupus are not known to cause panic
attacks
